The Institute for Healthcare Improvement discusses a new model for identifying patient safety issues in healthcare organizations in a new report.
The report, titled "Tapping Front-Line Knowledge: Identifying Problems as They Occur Helps Enhance Patient Safety" and published in Healthcare Executive, is based on a partnership of IHI and Cedars-Sinai Medical Center in Los Angeles that began in 2010 to address gaps in safety improvement initiatives.
One of the challenges in improving patient safety is ensuring everyone in the organization understands what constitutes patient safety. Sometimes, patient safety risks are not reported or identified because front-line workers do not recognize them as such, according to the report.
Neil Romanoff, MD, vice president for medical affairs and chief patient safety officer at Cedars-Sinai, and IHI leaders worked with Steve Spear, a researcher and author who had studied reliable industries outside of healthcare, to help front-line workers identify patient safety issues. Together, they developed a unit visit "conversation" designed to make front-line workers aware of patient safety problems as they occur.
The conversation includes four steps:
1. Organize the visit to the unit beforehand. A small leadership team should meet with a group of six to eight front-line staff for a conversation at least 60 minutes long.
2. Arrange for all participants to describe the jobs they do. The goal in this step is to understand the work and work environment.
3. Assess the work environment using "anchoring questions." Anchoring questions target specific events rather than patient safety as a whole. The report suggests leaders ask questions such as "When was the last time a case was delayed?" rather than "What safety concerns do you have?"
4. Debrief. In this stage, leaders debrief the team that asked the questions as well as the front-line team with a goal of gaining buy-in for possible action.
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The report, titled "Tapping Front-Line Knowledge: Identifying Problems as They Occur Helps Enhance Patient Safety" and published in Healthcare Executive, is based on a partnership of IHI and Cedars-Sinai Medical Center in Los Angeles that began in 2010 to address gaps in safety improvement initiatives.
One of the challenges in improving patient safety is ensuring everyone in the organization understands what constitutes patient safety. Sometimes, patient safety risks are not reported or identified because front-line workers do not recognize them as such, according to the report.
Neil Romanoff, MD, vice president for medical affairs and chief patient safety officer at Cedars-Sinai, and IHI leaders worked with Steve Spear, a researcher and author who had studied reliable industries outside of healthcare, to help front-line workers identify patient safety issues. Together, they developed a unit visit "conversation" designed to make front-line workers aware of patient safety problems as they occur.
The conversation includes four steps:
1. Organize the visit to the unit beforehand. A small leadership team should meet with a group of six to eight front-line staff for a conversation at least 60 minutes long.
2. Arrange for all participants to describe the jobs they do. The goal in this step is to understand the work and work environment.
3. Assess the work environment using "anchoring questions." Anchoring questions target specific events rather than patient safety as a whole. The report suggests leaders ask questions such as "When was the last time a case was delayed?" rather than "What safety concerns do you have?"
4. Debrief. In this stage, leaders debrief the team that asked the questions as well as the front-line team with a goal of gaining buy-in for possible action.
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